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CNA certification lecture Seizure DisordersJanuary 30 2013
Margo DeVries-Rizzo, BScN, MScN, RN(EC)Nurse Practitioner, Paediatric Neurology
Children’s Hospital, London Health Sciences CentreAdjunct Assistant Professor, Faculty of Health Sciences
University of Western Ontario
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ILAE Classification of SeizuresSeizures
Partial
Simple Partial
Complex Partial
Secondarily Generalized
Generalized
Absence
Myoclonic
Atonic
Tonic
Tonic-Clonic
With permission from www.aesnet.org
ILAE – International League Against Epilepsy
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Left
Right
Left
Right
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Partial seizures
Duration: 5-10 secondsMemory is preservedAuras ARE seizuresNote: Prodrome is the feeling prior to
seizure Somatosensory, motor, autonomic or
psychic symptoms Todd’s paresis may be presentOften minimal or no post-ictal period
Seizures
SIMPLE PARTIAL
Generalized
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Complex partial seizures Duration: 30 seconds to 2 minutes **IMPAIRED CONSCIOUSNESS** Automatisms Autonomic phenomena Eye, head deviation Contralateral movements ( motor, dystonic) May have brief post-ictal period Headaches common Todd’s paresis; expressive aphasia TIP: State a favorite thing during the seizure
and ask after what you said
Seizures
COMPLEX PARTIAL
Generalized
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With permission from www.aesnet.org
2013/01/30
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ILAE Classification of SeizuresSeizures
Partial
Simple Partial
Complex Partial
Secondarily Generalized
Generalized
Absence
Myoclonic
Atonic
Tonic
Tonic-Clonic
With permission from www.aesnet.org
ILAE – International League Against Epilepsy
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With permission from www.aesnet.org
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With permission from www.aesnet.org
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Seizures
Generalized
Atonic
• Sudden loss of postural tone • Severe – may fall• Milder – head nod, jaw
drop• “Drop attacks”• Usually impaired
consciousness• Duration: usually seconds
Atonic Seizures
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Generalized seizures
Onset without warning Loss of consciousnessOften begins with tonic phase Proceeds to clonic phase – rhythmic
bilateral contractionMassive autonomic outpouring –
tachycardia, hypertension, hypersalivation, pupillary dilationDuration: 30 seconds- 2 minutes Post-ictal - minutes to hours
Seizures
Generalized
Tonic Tonic/Clonic
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Nonepileptic
Reflex anoxic seizures Febrile seizures TIA – may appear as CPS Psychogenic seizures (pseudosz) Key * HISTORY
Eyes closed; Length of time; Emotional trigger; Unusual motor movements; Unusual non guttural vocalizations; May have incontinence
No EEG correlate Diagnosis of exclusion
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Frontal Lobe Symptoms
MOTOR movementsTurning away of eyesAphasiaHead, body turning
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Temporal Lobe Symptoms
Gastric phenomena Fear, panicAutonomic phenomenaOroalimentary and
gestural automatismsDystoniaAphasiaAuditory hallucinations
(buzzing, person’s voice)
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Parietal Lobe Symptoms
SENSORYVertigoContralateral
hemi-neglect Eyes may turn away
or toward side of seizure
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Occipital Lobe Symptoms
Simple geometric shapes Flashes of light
(contralateral visual field)Hallucinations
(flashing lights)
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Deciphering Seizures
HiSTORY Seizure progression?Localization Where?
Classification Focal? General?
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Case Study #1 Trevor is a 13 year old male who was recently
noted at school to be staring unresponsively with his head and eyes turned to the right. He was making some swallowing motions . At first his teacher thought he was goofing off because he kept grabbing at his shirt repeatedly with his left hand. Then she noticed his right hand was turned inward and very stiff. His pupils were very dilated and he was unresponsive. The total event lasted about 60 seconds. Afterwards Trevor seemed fine but complained of a headache for a ½ hour and recalls feeling “funny” and his “stomach bothering” him before the seizure started.
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Case Study # 2
Brenda is an 48 year old female underwent gross total resection of a large brain tumor. Six hours post op she suddenly grunted, became stiff with arms and legs outstretched, eyes open and rolled back, and her jaw was clenched. She then developed tonic and quickly clonic movements. She had drooling and mild cyanosis. The entire seizure lasted 2 minutes. Afterward she slept deeply for 3 hours.
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Deciphering Seizures
HiSTORY Seizure progression?Localization Where?
Classification Focal? General?
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Antiepileptic Drug Principles
Seizure type/ Epilepsy syndrome Treatment Strategies
(Pharmacodynamics) Pharmacokinetic profile ( ADME) Efficacy (ability to suppress seizures) Ease of UseAdverse effectsCost Interactions/other medical conditions
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AED Management Principles
Specific seizure type/epilepsy syndromeMonotherapy – Best if achievable Balance between No Seizures and No
(minimal) side effects Treatment based on effect on quality of
lifeMechanism of action goal is to make cell
membrane less excitable Side effects, drug interactions,
administration issues, protein binding
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Generic/Trade Names
Broad-Spectrum Agents
Valproate – Depakene, Epival
Lamotrigine - Lamictal
Topiramate - Topamax
Levetiracetam - Keppra
Clonazepam – Rivotril
Clobazam - Frisium
Absence
Ethosuximide – Zarontin
VPA; LAM
Narrower Spectrum Agents
Partial onset seizures
Phenytoin - Dilantin
Carbamazepine - Tegretol
Oxcarbazepine - Trileptal
Gabapentin - Neurontin
Primidone – Mysoline
Phenobarbital - same
Epileptic Spasms
ACTH –Cosyntropin (Synacthen Depot)
Vigabatrin (Sabril))
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Other anti-seizure meds
Lacosamide ( Vimpat)Rufinamide (Banzil)Felbamate*Zonisamide*Stiripentol*Pregabalin
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SEIZURE FIRST AID
CALM…….SAFE………TIME ROLL ON SIDE DO NOT INSERT ANYTHING IN MOUTH
DETAILS OF SEIZUREPROGRESSION
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RECORD THE SEIZURE EXACTLY
Remember to record the time and how the seizure progressed on the Seizure Record/Clinical Notes. The more detail you can provide, the better.
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RESPONDING TO A SEIZURE LASTING LONGER THAN 5 MINS
Give initial rescue med at five minutes Remember it takes 5-7 mins to work if NOT IV
Call 911 or a Code ( facility specific) ABCs Administer O2 Monitor Vital signs, O2 Sat Establish IV Access (2 lines) Blood work as directed – bld glucose, AED level*, gas Monitor for respiratory depression, hypotension,
arythmias Early treatment associated with the best outcome
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Rescue meds
Ensure order on chart for rescue med Usual drugs of choice:
Lorazepam (buccal/rectal)- 0.1 mg/kg – max 4 mg Midazolam (buccal) - 0.5 mg/kg – max 10 mg
or intranasal - 0.2 mg/kg – max 5 mg/nostril Diazepam (rectal) - 0.5mg/kg/dose – max 20 mg/dose
IV- not necessary unless prolonged seizure Status Epilepticus Note: Benzodiazepines affect GABA receptors which
decrease neuronal excitability
(Friedman, 2011)
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MANAGEMENT OF STATUS EPILEPTICUS
FIRST LINE ( Benzos) Lorazepam IV (0.05- 0.1 MG/KG) Max 4 mg Assess 1-5 minutes – may repeat. Administer at a rate of 2 MG/MIN Longer acting Safe to administer IV Lower risk of C-R depression
If SZ continues an additional dose is given 5-10 mins after first dose May give up to a cumulative dose of 8-10 mg
over 20 mins
(Friedman, 2011; Micromedex 2013)
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MGMT OF SE (cont’d)
DIAZEPAM 0.1 mg/kg IV or MIDAZOLAM 0.05 mg/kg IV may be substituted if lorazepam not available. If IV access is not available, midazolam 10mg IM for patients with a body weight >40kg and 5mg IM for patients with a body weight of 13 to 40kg is an alternative
http://www.uptodate.com
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Management of SE (cont’d)…
2ND LINE: Begins 10 mins after last IV dose Phenytoin ( Dilantin)15-20 mg/kg or max loading dose 1.5 - 2 gmMaximum rate, children: 50 mg/min or 1 - 3 mg/kg/min, whichever is less Adult rate: 50 mg/min To avoid hypotension, bradycardia and irritation to blood vesselsNO IM injection Only give with NS or flush before and after with NS
(Friedman, 2011)
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Management of SE (contd)
Fosphenytoin (Cerebyx) Rapidly converted to phenytoin The dose, concentration in solutions, and infusion rates for fosphenytoin are expressed as phenytoin sodium equivalents (PE); Fosphenytoin should always be prescribed and dispensed in phenytoin sodium equivalents (PE). Loading dose, 15 to 20 mg phenytoin sodium equivalents (PE)/kg IV at a rate of 100 to 150 mg PE/min Follow with maintenance doses of fosphenytoinor phenytoin Compatible with NS and D5W
(http://www.thomsonhc.com/micromedex2/librarian/...2013)
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Management of SE (contd)
Phenobarbital15 - 20 mg/kg ( neonates and children) or max loading dose 1 GramGive undiluted or further dilute with an equal volume of NS or D5W Do not exceed a rate of 1 mg/kg/minute or 30 mg/minute Rapid injection rate may cause serious respiratory depression Intubation/ventilation
(Friedman, 2011)
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Management of SE (contd)
3rd LINE: IV infusionICU – infusion – Midazolam or PentobarbitalContinuous EEG monitoring to keep in burst suppression
(Friedman, 2011)
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Resection
Invasive monitoring Strips, depths, or grid Functional mapping
no surgery surgery
Clinical Care Map
CONTINUE MEDSKETOGENIC DIET
-multifocal onset-generalized onset
-lateralize, localize -no risk for deficits
-lateralize-need clearer localization -risk for deficits
NON SURGICAL
SURGICAL
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Management
Treat underlying condition Education** (Sz and AED)Avoid precipitating factors (alcohol, drug, fatigue)Take medication regularlyKeep sz diaryKnow medicationsKnow AED action and side effectsKnow drug interactions
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Management
Counsel regarding living with uncertainty in illness/impact on quality of life Driving issues Women’s issues – OC, co-morbidities Teen issues Use cell phones (meds/reminders) Medic alert bracelet Seizure first aid response – family/caregivers Websites Epilepsy Support Centers Keep appointments
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References
Azar NJ and BW Abou-Khalil. Considerations in the choice of an antiepileptic drug in the treatment of epilepsy. Seminars in Neurology. 2008; 28(3): 305-316.
Friedman, JN. Emergency management of the paediatric patient with generalized convulsive status epilepticus. Paediatric & Child Health. 2011: (11(2). 91-97.
Guerrini, R. Epilepsy in children, The Lancet 2006;367: 499-523. Kanner, Andres M. Common errors made in the diagnosis and treatment
of epilepsy. Seminars in Neurology,. 2008; 28(3) : 364-378. http://www.uptodate.com/contents/status-epilepticus-in-adults.
Retrieved January 28, 2013.